Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) for Health Care Interventions: a Proposed Framework

'I am happy to be listened to': co-creation of a simple tool to measure women's experiences of respectful maternity care in urban Tanzania

BACKGROUND

Rights-based Respectful Maternity Care (RMC) is crucial for quality of care and improved birth outcomes, yet RMC measurements are rarely included in facility improvement initiatives. We aimed to (i) co-create a routine RMC measurement tool (RMC-T) for congested maternity units in Dar es Salaam, Tanzania, and (ii) assess the RMC-T's acceptability among women and healthcare stakeholders.

METHOD

We employed a participatory approach utilizing multiple mixed methods. This included a scoping review, stakeholder engagement involving postnatal women, healthcare providers, health leadership, and global researchers through interviews, focus groups, and two surveys involving 201 and 838 postnatal women. Cronbach's alpha and factor analysis were conducted for validation using Stata 15. Theories of social practice and Thematic Framework of Acceptability guided the assessment of stakeholder priorities and tool acceptability.

RESULTS

The multi-phased iterative co-creation process produced the 25-question RMC-T that measures satisfaction, communication, mistreatment (including physical, verbal, and sexual abuse; neglect; discrimination; lack of privacy; unconsented care; post-birth clean-up; informal payments; and denial of care), supportive care (such as food intake and mobility), birth companionship, post-procedure pain relief, bed-sharing, and newborn respect. The pragmatic validation process prioritized stakeholder feedback over strict statistics, lowering Cronbach's alpha from 0.70 in version 1 to 0.57 for the RMC-T. Women valued the opportunity to share their experiences.

CONCLUSIONS

The RMC-T is contextualized, validated, and acceptable for measuring women's experiences of RMC. Routine use in facility-based quality improvement initiatives, along with targeted actions to address gaps, will advance rights-based RMC. Further validation and community-based studies are needed.

Application of human-centered design principles to wearable exoskeletons: a systematic review

Purpose of the article: As technologies continue to advance, designing wearable exoskeletons that are comfortable, safe, reliable, and engaging for users is an arduous task. The integration of HCD principles in exoskeleton development significantly contributes to ensuring that the product meets the needs and preferences of users. This study systematically reviews the application of human-centred design (HCD) principles in the development of wearable exoskeletons.

Methodology: It synthesizes existing literature, identifies key HCD concepts and assesses their impact on exoskeleton usability, comfort, and safety. The findings of the study revealed a moderate application of HCD in many of the studies; however, the concepts were found to play a crucial role in enhancing the usability, safety, and comfort of wearable exoskeleton technology implementation. Challenges revealed in the study include limited stakeholder involvement, a lack of standardized evaluation metrics, non-consideration of ethical, legal, and social issues, and a lack of studies on the potential adverse effects of exoskeleton use. Besides identifying the challenges faced in integrating HCD principles into exoskeleton development, the study also proposed pragmatic approaches to overcome them.

Results: The study underscores the significance of incorporating human-centred design principles in the design and development of wearable exoskeletons. This has implications for industry, rehabilitation, health, and agriculture to churn out positive outcomes. The research contributes to the expanding literature on wearable exoskeletons and HCD, offering valuable insights into the advancement of this technology in various domains and suggesting areas for future studies to address identified gaps.

Opportunities to Apply Human-centered Design in Health Care With Artificial Intelligence-based Screening for Diabetic Retinopathy

Diabetic retinopathy (DR) is a leading cause of blindness. Artificial intelligence (AI) has been proposed to provide a novel opportunity to increase screening for DR. While it is paramount to ensure AI has adequate technical capabilities to perform accurate screening, it is also important to assess how to best implement such technology into clinical practice. Human-centered design offers a methodology to understand the real-world context and behaviors of individuals, engage stakeholders, and rapidly prototype and test solutions, enhancing usability and avoiding unintended consequences. This review describes the methodology of human-centered design, examining how it has been used within a variety of health care contexts, with a particular focus on how it has been used to implement an AI-based DR screening program. Further research is needed to understand the best strategies to implement and evaluate AI in health care.

Development of a 12-Week Unsupervised Online Tai Chi Program for People With Hip and Knee Osteoarthritis: Mixed Methods Study

BACKGROUND

Osteoarthritis is a leading contributor to global disability. While evidence supports the effectiveness of Tai Chi in improving symptoms for people with hip/knee osteoarthritis, access to in-person Tai Chi classes may be difficult for many people. An unsupervised online Tai Chi intervention for people with osteoarthritis can help overcome accessibility barriers. The Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) framework provides a practical guide for co-designing such an intervention.

OBJECTIVE

This study aims to develop an unsupervised online Tai Chi program for people with hip/knee osteoarthritis.

METHODS

An iterative process was conducted using the AHEAD framework. Initially, a panel of Tai Chi instructors and people with osteoarthritis was assembled. A literature review was conducted to inform the content of a survey (survey 1), which was completed by the panel and additional Australian Tai Chi instructors to identify Tai Chi movements for potential inclusion. Selection of Tai Chi movements was based on 3 criteria: those that were appropriate (for people with hip/knee osteoarthritis aged 45+ years), safe (to be performed at home unsupervised), and practical (to be delivered online using prerecorded videos). Movements that met these criteria were then ranked in a second survey (survey 2; using conjoint analysis methodology). Survey findings were discussed in a focus group, and the Tai Chi movements for program use were identified. A draft of the online Tai Chi program was developed, and a final survey (survey 3) was conducted with the panel to rate the appropriateness and safety of the proposed program. The final program was developed, and usability testing (think-aloud protocol) was conducted with people with knee osteoarthritis.

RESULTS

The panel consisted of 10 Tai Chi instructors and 3 people with osteoarthritis. The literature review identified Yang Style 24 as a common and effective Tai Chi style used in hip/knee osteoarthritis studies. Surveys 1 (n=35) and 2 (n=27) produced a ranked list of 24 Tai Chi movements for potential inclusion. This list was refined and informed by a focus group, with 10 Tai Chi movements being selected for inclusion (known as the Yang Style 10 form). Survey 3 (n=13) found that 92% (n=12) of the panel members believed that the proposed draft Tai Chi program was appropriate and safe, resulting in its adoption. The final program was produced and hosted on a customized website, "My Joint Tai Chi," which was further refined based on user feedback (n=5). "My Joint Tai Chi" is currently being evaluated in a randomized controlled trial.

CONCLUSIONS

This study demonstrates the use of the AHEAD framework to develop an unsupervised online Tai Chi intervention ("My Joint Tai Chi") for people with hip/knee osteoarthritis. This intervention is now being tested for effectiveness and safety in a randomized controlled trial.

A narrative review of factors affecting memory confidence in the context of compulsive checking: A search for evidence-based potential therapeutic targets to improve memory confidence

BACKGROUND AND OBJECTIVES

According to current models of compulsive checking, memory confidence greatly contributes to the development and maintenance of checking behaviours. However, how to intervene in memory confidence in an evidence-based manner has not yet been fully understood. Thus, the purpose of the current paper was to identify the factors influencing memory confidence through the review of experimental evidence.

METHODS

PubMed, Google Scholar, OpenGrey and ProQuest databases were searched by combining two sets of keywords related to memory confidence and checking. Our search yielded 24 experiments. Due to the considerable heterogeneity of the studies regarding questionnaires, tasks and paradigms used, data were synthesized using a narrative review approach.

RESULTS

Six factors emerged from a thorough review of the literature, including negative memory belief, higher memory standard, inflated sense of responsibility, familiarization with the checked stimuli, number of checks and anxious valence of the checked stimuli.

CONCLUSION

The findings have important implications for the treatment of compulsive checking. We suggested general guidelines to translate these factors into a novel intervention to increase memory confidence in compulsive checkers.

"As a patient I do not belong to the clinic, I belong to the community": co-developing multi-level, person-centred tuberculosis stigma interventions in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework.

Results

Intervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00084-z.

Do medical devices contribute to sustainability? Environmental, societal and governance aspects

Sustainability of a product or device is currently primarily related to its environmental footprint. Here, a wider concept of sustainability is introduced for medical devices and their components in healthcare provision. Such devices sustain healthcare and patient wellbeing due to their quality specifications for material composition, product design and performance. The term quality must be intended in the most comprehensive term, including purity and biocompatibility of materials, device reliability, limited number of recalls and reduced risks as well as acceptability for patients. A close look on medical device specification shows, however, that additional parameters, such as societal, demographic and economic factors also determine medical device sustainability. The medical device life cycle, from design phase, production process to clinical application and the final disposal, also determines its impact. Recommendations for healthcare operators and managers will complete the hypothesis of this paper, that a thoroughly outlined device choice and operation together with a careful waste management of spent medical devices and their components positively affects medical device sustainability. As an example, the limited quantity of wastes and the reduced risks for adverse reaction have a positive impact on both the environmental pollution and on the costs sustained by the healthcare organisations and by the community. These factors determine both, the success of healthcare manoeuvres and the related environmental footprint.

Barriers to person-centered service design in pharmacy practice: examples, lessons, and potential solutions

Despite increased attention to, and frameworks conceptualizing person-centered care, systematic, organizational, and provider-level barriers continue to discourage the development and delivery of person-centered care (PCC) in pharmacy practice and beyond. This commentary describes existing pharmacy-specific literature related to PCC, barriers to PCC within the context of pharmacy practice, and potential solutions to increase person-centeredness in pharmacy services. Literature to substantiate and describe barriers and potential solutions was identified from 2008 to 2023, a period where the emphasis on PCC in pharmacy practice dramatically increased. Overall, pharmacy-specific literature was identified describing four key barriers to PCC. Several potential solutions were identified, including: using innovative and theory-informed approaches to collecting individual need and preference information, employing processes and equipping providers to facilitate trust, changing organizational culture, and aligning quality metrics and financial incentives with PCC. Identified solutions may be used to address individual, organizational, and systematic barriers to promote PCC.

Women in Health and their Economic, Equity and Livelihood statuses during Emergency Preparedness and Response (WHEELER) protocol: a mixed methods study in Kenya

INTRODUCTION

Kenya reported its first COVID-19 case on 13 March 2020. Pandemic-driven health system changes followed and unforeseen societal, economic and health effects reported. This protocol aims to describe the methods used to identify the gender equality and health equity gaps and possible disproportional health and socioeconomic impacts experienced by paid and unpaid (community health volunteer) female healthcare providers in Kilifi and Mombasa Counties, Kenya during the COVID-19 pandemic.

METHODS AND ANALYSIS

Participatory mixed methods framed by gender analysis and human-centred design will be used. Research implementation will follow four of the five phases of the human-centred design approach. Community research advisory groups and local advisory boards will be established to ensure integration and the sustainability of participatory research design.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Scientific and Ethics Review Committee at the Aga Khan University and the University of Manitoba.This study will generate evidence on root cultural, structural, socioeconomic and political factors that perpetuate gender inequities and female disadvantage in the paid and unpaid health sectors. It will also identify evidence-based policy options for future safeguarding of the unpaid and paid female health workforce during emergency preparedness, response and recovery periods.

"As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.

Results

Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Planting Seeds for Food Is Medicine: Pre-Implementation Planning Methods and Formative Evaluation Findings From a Multi-Clinic Initiative in the Midwest

Food is medicine (FIM) initiatives are an emerging strategy for addressing nutrition-related health disparities increasingly endorsed by providers, payers, and policymakers. However, food insecurity screening protocols and oversight of medically-tailored food assistance programs are novel for many healthcare settings. Here, we describe the pre-implementation planning processes used to successfully engage federally-qualified health centers (FQHCs) across Kansas to develop new FIM initiatives. A Kansas-based philanthropic foundation facilitated pre-implementation planning for FQHCs over 17 months across 3 stages: 1) Community inquiry, 2) FIM learning event with invitation for FQHC attendees to request pre-implementation funding, and 3) Pre-implementation planning workshops and application assignments for FQHC grantees to develop a FIM implementation grant proposal. We evaluated satisfaction and perceived utility of these pre-implementation planning activities via post-workshop surveys and qualitative comparisons of FIM design components from pre-implementation and implementation grant applications. All 7 FQHCs attending the learning event applied for and were awarded pre-implementation planning grants; 6 submitted an implementation grant application following workshop completion. FQHCs rated pre-implementation support activities favorably; however, most clinics cited limited staff as a barrier to effective planning. As compared to pre-implementation planning grant proposals, all FQHCs elected to narrow their priority population to people with pre-diabetes or diabetes with better articulation of evidence-based nutrition prescriptions and intervention models in their final program designs. In the midst of a nationwide FIM groundswell, we recommend that funders, clinic stakeholders, and evaluators work together to devise and financially support appropriate pre-implementation planning activities prior to launching new FIM initiatives.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BACKGROUND

Responsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.

METHODS

We completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2-4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.

RESULTS

All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.

CONCLUSIONS

Using a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Incorporating the HIV Infant Tracking System into standard-of-care early infant diagnosis of HIV services in Kenya: a cost-effectiveness analysis of the HITSystem randomised trial

BACKGROUND

The HITSystem efficacy trial showed significant improvements in early infant diagnosis retention, return and notification of infant test results, and earlier antiretroviral therapy (ART) initiation compared with standard-of-care early infant diagnosis services in Kenya. This study aimed to analyse data from the HITSystem trial to assess the cost-effectiveness of the intervention in Kenya.

METHODS

In this analysis, we extrapolated results from the HITSystem cluster randomised controlled trial to model early infant diagnosis outcomes and cost-effectiveness if the HITSystem was scaled up nationally in Kenya, compared with standard-of-care outcomes. We used a micro-costing method to collect cost data, which were analysed from a health-system perspective, reflecting the investment required to add HITSystem to existing early infant diagnosis services and infrastructure. The base model used to calculate cost-effectiveness was deterministic and calculated the progression of infants through early infant diagnosis. Differences in progression across study arms were used to establish efficacy outcomes. The number of life-years gained per infant successfully initiating ART were based on the Cost Effectiveness of Preventing AIDS Complications model in east Africa. HITSystem cost data were integrated into the model, and the incremental cost-effectiveness ratio was calculated in terms of cost per life-year gained. Sensitivity analyses were done using the deterministic model with triangular stochastic probability functions for key model parameters added. The number of life-years gained was discounted at 3% and costs were adjusted to 2021 values.

FINDINGS

The cost per life-year gained from the HITSystem was US$82·72. Total cost for national HITSystem coverage in Kenya was estimated to be around $2·6 million; covering 82 230 infants exposed to HIV at a cost of $31·38 per infant and a yield of 1133 infants receiving timely ART, which would result in 31 189 life-years gained. With sensitivity analyses, the cost per life-year gained varied from $40·13 to $215·05. 90% of model values across iterations ranged between $55·58 (lower 5% threshold) and $132·38 (upper 95% threshold).

INTERPRETATION

The HITSystem would be very cost-effective in Kenya and can optimise the return on the existing investment in the national early infant diagnosis programme.

FUNDING

The US National Institute of Child Health and Human Development.

Pre-service midwifery education in sub-Saharan Africa: A scoping review

BACKGROUND

In response to a global call for more midwives, maternal health stakeholders have called for increased investment in midwifery pre-service education. Given the already long list of challenges and the increasing burden on health care systems due to the COVID-19 pandemic, the need to prioritize investment is acute, particularly in sub-Saharan Africa. An important first step is to examine the current evidence.

METHODS

We conducted a scoping review of the peer-reviewed literature about pre-service midwifery education in sub-Saharan Africa. A search of studies published between 2015 and 2021 in French or English was conducted using six databases (PubMed, CINAHL, Embase, Scopus, Web of Science and African Index Medicus).

RESULTS

The search yielded 3061 citations, of which 72 were included. Most were a mix of qualitative and quantitative cross-sectional, country-specific studies. Organized by pre-service educational domain, the literature reflected a misalignment between international standards for midwifery education and what schools and clinical sites and the larger administrative systems where they operate, reliably provide. Inadequate infrastructure, teaching capacity in school and clinical settings and clinical site environment were factors that commonly impede learning. Literature related to faculty development and deployment were limited.

CONCLUSION

Schools, faculty and clinical sites are overwhelmed yet recommendations by key stakeholders for change are substantive and complex. Efforts are needed to help schools map their current status by pre-service education domain and prioritize where scarce resources should be directed. These results can inform research and investments in pre-service midwifery education in sub-Saharan Africa.

Equity and bias in electronic health records data

Embedded pragmatic clinical trials (ePCTs) are conducted during routine clinical care and have the potential to increase knowledge about the effectiveness of interventions under real world conditions. However, many pragmatic trials rely on data from the electronic health record (EHR) data, which are subject to bias from incomplete data, poor data quality, lack of representation from people who are medically underserved, and implicit bias in EHR design. This commentary examines how the use of EHR data might exacerbate bias and potentially increase health inequities. We offer recommendations for how to increase generalizability of ePCT results and begin to mitigate bias to promote health equity.

Factors Affecting Performance of Insulin Pen Injector Technology: A Narrative Review

BACKGROUND

Insulin treatment is an essential hormone replacement therapy for the survival of people with type 1 diabetes and is often used for treatment in type 2 diabetes, particularly as the disease progresses. Advances in insulin therapy have been made since its discovery, including production of human insulin and development of insulin analogs with improved efficacy and safety profiles. The different types of available insulin formulations allow health care professionals to personalize treatment to an individual's needs. Generally, insulin requires parenteral administration via subcutaneous injection owing to very low oral bioavailability.

METHODS

This article reviews the human, technological, economical, and regulatory factors affecting the performance of insulin pens and the relationship between them. Opportunities and challenges that insulin pen injections may encounter in the future are also considered.

RESULTS

Insulin delivery devices, together with other factors, influence dose accuracy, convenience, and quality of life, contributing to easier medication administration with high efficacy and safety. For patients, ease of use, fast and accurate drug delivery, and painless injection are the most valuable features of an insulin injection device. For manufacturers, technological feasibility and economic viability also need to be considered when developing injection devices.

CONCLUSION

Insulin pen injectors are generally preferred over vial and syringe, although access may be limited in some health care systems. Insulin pen injectors can adapt to different insulin regimens and formulations and have the potential to acquire dosing data in real time.

Understanding Factors Influencing Polio Vaccine Uptake in Ghana-Developing Meaningful Community Mobilization and Engagement Strategies in Collaboration with Religious Leaders

This qualitative study explores how religious leaders in Ghana view polio and polio vaccine-related knowledge and perceptions of the community members. It also examines the personal characteristics of those who are most likely to accept or reject the vaccine. On the basis of the findings, this study provides a set of evidence-based recommendations to support religious leaders' efforts to create polio vaccine demand in their communities. The study is based on focus group discussions conducted with religious leaders from various geographic locations across Ghana. The discussions were transcribed verbatim and analyzed thematically. Twenty religious leaders, including Christian, Muslim, and leaders of traditional African religions, participated in the study. The findings show that both religious leaders and community members lack knowledge and have multiple culturally and religiously influenced explanations for polio. In addition, the findings reveal that vaccine safety and efficacy are linked to emotional narratives, and receiving the polio vaccine is not a social norm in all communities. Educated mothers in urban settings were identified as those most receptive to the polio vaccine. To create polio vaccine demand, religious leaders need to combat misinformation and the negative perceptions about the vaccine. Recommendations include conveying high-quality information to community members, developing tactics to address culturally and religiously sensitive matters, using emotionally inspired personal accounts to enhance positive attitudes toward polio vaccines and act as catalysts for positive social norms towards the polio vaccine. Educated mothers from urban areas can be engaged as champions in vaccine demand creation.

The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients

OBJECTIVE

To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.

DATA SOURCES

Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.

STUDY DESIGN

This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.

DATA COLLECTION METHODS

Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.

PRINCIPAL FINDINGS

The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.

CONCLUSION

P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

Quality of Life Improvement: A Novel Framework and Approach to Well-Being

Physician burnout is a complex problem that requires creative solutions. Despite increasing awareness of the importance of systems approaches to address physician well-being, few tools exist for organizations to bridge the gap between well-being theory and practice. As demonstrated during the COVID-19 pandemic, new threats to well-being can arise at any time, necessitating an iterative approach. Here we outline the quality of life improvement (QOLI) approach, a novel framework and approach that incorporates principles of human-centered design (HCD), quality improvement (QI), and implementation science (IS) to address clinician well-being. Additionally, we share our experience using this approach in a large academic anesthesiology department.

Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study

Importance

Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity.

Objective

To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting.

Design, Setting, and Participants

Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers.

Main Outcomes and Measures

Antiracism practices adapted to medicine.

Results

Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters.

Conclusions and Relevance

This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.